Provider Demographics
NPI:1124129697
Name:P D MEDICAL, S.C.
Entity type:Organization
Organization Name:P D MEDICAL, S.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:B
Authorized Official - Last Name:DRAGISIC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-636-1466
Mailing Address - Street 1:4201 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2615
Mailing Address - Country:US
Mailing Address - Phone:708-636-1466
Mailing Address - Fax:708-636-0264
Practice Address - Street 1:4201 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2615
Practice Address - Country:US
Practice Address - Phone:708-636-1466
Practice Address - Fax:708-636-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636324OtherBCBS
ILDG6568OtherRAILROAD MEDICARE
IL016092116Medicaid
IL016092116Medicaid